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Please print or type.(Form designed for use on elite(12-pitch)typewriter.) Form Approved,OMB No.2050.0039 <br /> UNIFORM HAZARDOUS 1.Generator lD Number 2.Page 1 of 3,Emergency Response Phare 4,Manifest Tra'ck�ing6Number , 6 <br /> WASTE MANIFEST ChLC1t3Q 717` 1 416-823-8172a..g92436 FLE <br /> S.Generator's Name and MaTingUCf1 R�ALSVCRLG'YGUt+ Nn 1f1MlTfdOff nereta'sReAddress(ifddterantUranmailingaddrass) <br /> 32030 S:8 Domd t St:. <br /> VOC141Ct1,CA <br /> Generators Phone: <br /> 2094-44-9M <br /> rampooter 1 Company Name U.S.EPA ID Number <br /> Union Psaft Lines Co NEDI X317&2910 <br /> 7.Transpoder 2 Company Name U.S.EPA ID Number <br /> 8.Designated Facility Name and SiteAddress U.S.EPA 10 Number <br /> I#D f OT}t'a UTCO93012201 <br /> West HOW4W 123 <br /> ESSt a€bOn,UT 54520 USA <br /> FaciGys Phone: <br /> Ila, 9b.U.S,DOT Description(indA4V Proper Shipping Name,Hazard Class,to Number, to.Containers 11:Total 12,Unit 13,Waste Cafes <br /> HM and Packing Group(d any)) No, Type. Quantity WtNOI, <br /> 1 <br /> NONLIRCRA'947AMOUS WASTE,S (fes-DOT d) 001 H .��� T �i t <br /> z 2. <br /> w <br /> ca <br /> 4. <br /> 14,Special Handling InsWctronSand Addiliaral information <br /> U Pt L*f*CYCUW PR GT RAOLCAR pdLl t <br /> ECt f 1 16 � _ 6 f� d <br /> 16. GENERATOR'SIOFFEROR'S CERTIFICAMON.I hereby declare that the contents of this consignment aro fully and accurately descdbed above by 0he proper sfWp$V rgrne,and are dassW packaged, <br /> marked and labeledlplacarded,and are In all respects In propercondtion for transport according to applic"intematib-W and national governmental regulations.If export st ment acid I am the Rdmary <br /> Exporter,I certify that the contents of this consignment ooniorm to the terms of the attached EPAA*wMedgment of Consent <br /> 1 certify that the waste minknizatiat statement Identified in 40 CFR 26227(a)(d 1 art a latge Quantity generator)or(b)fd I am a swall quantity ),s hue. <br /> N—wWs1NRVs Kntodrryped Nam 5griature Month Vay ear <br /> 7 ; <br /> J. f8.tntsmational$tQpmenls ❑ExpathomU.$, 'Patoten lexib <br />� i:•- ❑Impaf to U.S. try <br /> T <br /> (for exports ontili Date Waft U.S.: <br /> W 17 TmmnsporterAdcnbwledgment of RecW of Mauls <br /> i rerwitenl Rnted/Typed Name nature Month Day •ear <br /> i <br /> Q Transporter 2 PrintedlTyped Name , nature monm Uay Year <br /> 1 <br /> 18.Discrepancy, <br /> 18a.Discrepancy Indication Space 1:1Quanfity ❑Typo ❑Residua 1:1PeruRejection ❑Full Rejedian <br /> Manifest Reference Number. <br /> 18b.Altemate Facility(or Generator) U.S.EPA ID Number <br /> FaCti' s Ptwne: <br /> t8c Signature ofAftemate Facility{or Generator) Month Day Year <br /> 3 d <br /> N19,Hazardous Waste Report Management Method Codes(Le,,codes for hazardous waste treatment;ftosai,and recydiV systems) <br /> � 11 � 12. 3. 4. , <br /> t <br /> 20.Designated Facility Oh*or Operator:Certification of receipt othazardous materials covered by the manifest except as rioted in item 18a, <br /> RintedfTyped Name Signature Month Ye <br /> EPA Form 8700.22(Rev.US) Previous editions are pbsolete DESIGNATED ACRfY TO GENERATOR SATE(IF REQUIRED) <br /> E <br />